Drop Off Form Date* Client Name* First Last Phone*Alt PhoneEmail Pet's name*What kind of animal?*DogCatAge*Weight*Notes (e.g. aggressive, has seizures, does not like picture taken, etc.)Reason for visit* Wellness Sick Recheck Sedation X-rays Other If other, please explainSymptoms presented*These concerns are:PreviousOn-goingWhen did symptoms start?*Since problem was first noticed, are symptoms:*ImprovingWorseningStaying the sameIs your pet: (check all that apply)* Eating Drinking Urinating Defecating Is your pet's eating, drinking, urination, or defecation abnormal? If so which one(s)?Is your pet: (check all that apply)* Vomiting Sneezing Coughing Lethargic None of the above If you selected any of the above choices, how often is it happening?If your pet is currently on heartworm prevention, what product and when was it last given:If your pet is currently on flea prevention, what product and when was it alast given:Is your pet on any current medication (List any pain meds, antibiotics, heart meds, seizure meds, suppliments, etc.)Type of food pet is on?*How often eating?*Any special treats of dietary requirments?Is pet current on vaccines?*YesNoNot sureAny vaccines needed today? Rabies DHPP FVRCP Bordetella Lepto FeLV Flu Pre approval for servicesExam ($45)Sedation ($75)X-rays ($120)Basic Bloodwork ($100)Extensive Bloodwork ($200)Urinalysis ($40)Fecal Exam ($25)Heartworm Test ($30)FeLV/FIV Combo Test ($35)Deworming ($10-20)Hw/Flea Prevention ($10-20)Select all services you would approve if they were needed for a diagnosisClient's Signature*Signature Date* NameThis field is for validation purposes and should be left unchanged.